=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326230012
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GIRLS JUST WANNA HAVE FUN, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2007
-----------------------------------------------------
Last Update Date | 08/15/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4800 N SAGINAW RD
-----------------------------------------------------
City | MIDLAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48640-2953
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-631-4545
-----------------------------------------------------
Fax | 989-631-9949
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4800 N SAGINAW RD
-----------------------------------------------------
City | MIDLAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48640-2953
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-631-4545
-----------------------------------------------------
Fax | 989-631-9949
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | RESIDENT AGENT
-----------------------------------------------------
Name | DR. JAN DRLIK
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 989-631-4545
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------